2019 GUIDE OPEN ENROLLMENT - HEALTHCARE AND OTHER BENEFITS

 
CHICAGO
                              BENEFITS OFFICE

               HEALTHCARE AND OTHER BENEFITS
           OPEN ENROLLMENT
                GUIDE
                                    2019

                                        CITY OF CHICAGO

For non-represented employees, and for employees covered under the City’s collective
bargaining agreements with: The American Federation of State, County and Municipal
Employees Council 31, Coalition of Unionized Public Employees (Chicago Building Trades
Coalition); Illinois Nurses Association; Public Safety Employees Unit II; Police Captains Association,
Police Lieutenants Association, and Police Sergeants represented by the Policemen’s Benevolent
& Protective Association of Illinois (PB&PA); Supervising Police Communications Operators
represented by Teamsters Local 700; Aviation Security Sergeants represented by the Illinois Council
of Police; Public Health Nurse III’s and IV’s represented by Teamsters Local 743, and Uniformed
Firefighters and Paramedics represented by the Chicago Fire Fighters Union Local No. 2 and the
Shift Supervisors of Security Communications Center represented by Teamsters Local 700.
TABLE OF CONTENTS

Letter from
       from Labor
            Labor Management
                  Management Cooperation
                             CoorperationCommittee
                                          Committee.......................................................................................1,2
                                                      ..............................................................................1,2

Welcome to Open
Welcome to AnnualEnrollment
                  Open Enrollment     2019 ........................................................................................................3
                            2017 .............................................................................................................................3
Check Your Benefit Coverage Sheet.....................................................................................................................4
Check Your Benefit Coverage Sheet..............................................................................................................................4
Instructions On How To Access www.cityofchicagobenefits Portal......................................................................5
Adding a Dependent......................................................................................................................................................5
Adding a Dependent.........................................................................................................................................6,7
New Benefits for 2017..............................................................................................................................................6 ,7,8
Enroll or Re-Enroll in a Flexible Spending Account (FSA).....................................................................................8
PPO Money Savings........................................................................................................................................................9
Special Reminders.................................................................................................................................................9
Medical PPO (Blue Choice Options)............................................................................................................................10
Health Care Contribution Rates (Union and Non-Union)....................................................................................10
PPO Pre-certification by Telligen..................................................................................................................................11
Health Care Contribution Rates (Crossing Guards)............................................................................................11
PPO
PPO Prescription Drug Program...................................................................................................................................12
    Money Savings............................................................................................................................................12

HMO  (Blue
Medical PPOAdvantage HMO)
            (Blue Choice   Benefits Summary.......................................................................................................13
                         Options)...................................................................................................................13

PPO
HMOPre-certification by Telligen........................................................................................................................14
    Emergency Care..................................................................................................................................................14

PPO
HMOPrescription
    PrescriptionDrug Program.........................................................................................................................15
                Drugs...............................................................................................................................................15
HMO (Blue Advantage HMO) Benefits Summary...............................................................................................16
Dental PPO and Dental HMO Program.......................................................................................................................16
HMO Emergency Care........................................................................................................................................17
Vision Program...............................................................................................................................................................17
HMO Prescription Drugs.....................................................................................................................................18
Wellnes Program...........................................................................................................................................................18
Dental PPO and Dental HMO Program..............................................................................................................19
Life Insurance, Long Term Disability and Deferred Compensation..........................................................................19
Vision Program....................................................................................................................................................20
Flexible Spending Account..........................................................................................................................................20
Wellness Program................................................................................................................................................21
Health Care Contributions.......................................................................................................................................21,22
Life Insurance, Long Term Disability, Deferred Compensation and Voluntary Supplemental Insurance......22,23
Reminder
Reminder About
         About Fraud.................................................................................................................................................23
               Fraud.......................................................................................................................................24

Divorced Spouse’s
Benefit Fair       Healthcare
             Dates and        Coverage....................................................................................................................23
                       Locations........................................................................................................................25

Blue Cross
Benefit FairBlue
            DatesShield Online.............................................................................................................................26
                   and Locations.................................................................................................................................24

Contact ListOnline/Annual
Blue Cross   for Benefit Service
                           HealthProviders. ....................................................................................................27,
                                  Care Reminder/Charitable                                                                                            28
                                                                          Giving......................................................................25
Legal Notices......................................................................................................................................................29
Contact List for Benefit Service Providers...............................................................................................................26,27
Chicago Labor Management
                                           Cooperation Committee
                                                                                                               October 2018

Dear Employees:

For the past 12 years, the City of Chicago and labor representatives, working together in the
Labor Management Cooperation Committee (LMCC), have been engaged to keep your employee
benefits package working for you. Below we have listed a few highlights from 2018:

    recent report to the LMCC on the Chicago Lives Healthy Wellness Plan showed results since
1. A
   the program began in 2012. Primarily, the Wellness Plan appears to have improved member
   awareness. In addition, members showed behavioral and status improvements. For example,
   the number of individuals deemed to be “high-risk” for developing cardiovascular disease
   decreased by 17% over the six years of the program (from 2012 to 2018). Likewise, the number
   of individuals at “elevated risk” for developing diabetes decreased by 8%.

    art of the Wellness Plan involves special outreach, the Health Improvement Plan, or HIP, for
2. P
   members who were identified by Telligen as being at-risk, based upon biometric screening.
   This includes members with metabolic syndrome, who may have special risk for developing
   type 2 diabetes and/or cardiovascular disease. Telligen reported that 97% of the HIP participants
   displayed signs of metabolic syndrome in their first screening for the wellness program. But the
   percentage of those same HIP participants with metabolic syndrome dropped to 54% in 2018—
   in other words, 43% of the HIP participants improved their health status enough to no longer
   have metabolic syndrome.

    he LMCC received a $95,000 grant from the Federal Mediation and Conciliation Service.
3. T
   With Blue Cross, Healthways and Telligen, the LMCC used the grant to study new ways of
   communicating with members to increase engagement. The pilot outreach program is focusing
   on telemedicine, preventive dental hygiene, hypertension and hyperlipidemia.

    n additional, voluntary program for members with hypertension and hyperlipidemia started
4. A
   in 2018. Members receive counseling related to nutrition, weight reduction and increased
   physical activity.

    ith Blue Cross, the LMCC continues its telemedicine program, also known as Virtual Visits,
5. W
   through an entity called MDLive. Check out the ease of accessing Board-certified doctors right
   from your own home. A quick call to MDLive can save time and trouble—the MDLive “doctor is
   in” 24/7! Go to MDLive.com/bcbsil or call 1-888-676-4204 for more information.

Plan A effective 1/1/2019. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the
rank of Sergeant and Seasonal Employees). The Plan Document and subsequent updates always supersede this summary.
                                                                                                                                1
6. B
    est Doctors, the program for second opinions that started in 2017, reported continued success
   in 2018. Best Doctors offers timely, highly respected second opinions. They also offer counseling
   for chronic conditions, answers to treatment questions and can help you locate an in-network
   specialist who is a “Best Doctor.” Members used this service for, among other things, to receive
   information on treatment options for orthopedic complaints.

7. T
    iered PPO plan: In-network PPO hospitals, doctors and other providers are in one of two tiers
   in the OPT PPO plan. Tier I providers offer the most savings for both the City and members; Tier
   II providers have higher co-payments and out of pocket expense for members.  Members can
   choose providers from either tier, and they can go back and forth between tiers during the year
   at each provider visit. The tier approach has realized substantial savings in a number of areas for
   both the plan and LMCC members.

8. E
    mergency Room Use: On its website Blue Cross posts many alternatives to emergency rooms.
   Members save for themselves and for everyone by using urgent care centers, retail clinics,
   telemedicine (MDLive) and after-hour physicians.

We ask our members to take advantage of all the programs and information that we continue
to offer.

The LMCC thanks you for all your help in slowing down the growth of health benefit costs. We look
forward to working with you to continue to improve your health in 2019.

Sincerely,

The City of Chicago Labor Management Cooperation Committee

Plan A effective 1/1/2019. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the
rank of Sergeant and Seasonal Employees). The Plan Document and subsequent updates always supersede this summary.
2
WELCOME TO ANNUAL OPEN ENROLLMENT
                        October 17, 2018 through October 31, 2018
                    Open Enrollment Changes are Effective January 1, 2019
Open enrollment is the time of year when you can:
P Enroll in or cancel your medical, vision, or dental insurance
P Switch medical or dental plans
P Add dependents to your plan (for example a spouse, civil union or same sex domestic partner,
  or children)
P Drop dependents from your plan
P Enroll or re-enroll in a healthcare and/or dependent care Flexible Spending Account (FSA)
P Buy optional life insurance or voluntary long term disability insurance

To make changes, go to the City of Chicago Benefits Services Center website:

                                        www.cityofchicagobenefits.org

Open enrollment changes can also be made over the phone by calling:

                                 Benefits Service Center 1-877-299-5111

         Special hours during open enrollment: Monday through Friday 8:00 a.m. until 6:00 p.m.
                   Special hours Saturday, October 27, 2018 8:00 a.m. until 6:00 p.m.

Enrollment in a Flexible Spending Account (FSA) does not carry over from year to
       year. You must re-enroll in an FSA if you want this benefit for 2019.
Enroll online at www.cityofchicagobenefits.org or call the Benefits Service Center

                                                What Is New in 2019
ConnectYourCare is the City’s new vendor for healthcare and dependent care Flexible Spending
Accounts and transit benefits. Improvements include:
• One vendor replaces the two existing vendors - one stop shopping!
• You will have the option of a debit card for healthcare flexible spending account.

In the near future you will receive communications regarding the change to ConnectYourCare.

CVS Caremark is our new vendor for pharmacy benefits in the BCBS HMO, replacing Prime Therapeutics
for the HMO. In the near future you will receive communications regarding the change with instructions
that you or your doctor will need to follow to ensure no interruption in your prescriptions.

CVS Caremark continues to provide pharmacy benefits to PPO enrollees.

Plan A effective 1/1/2019. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the
rank of Sergeant and Seasonal Employees). The Plan Document and subsequent updates always supersede this summary.
                                                                                                                                3
CHECK YOUR BENEFIT COVERAGE SHEET
Your personalized Benefits Coverage Sheet is included with this Guide. The medical, dental and vision
enrollment listed on this Coverage Sheet will remain the same for 2019 unless you make changes during
the open enrollment period which runs October 17, 2018 through October 31, 2018. You must re-enroll in
healthcare and dependent care Flexible Spending Account(s) to participate in 2019.

Dependent children who reach the age of 26 are automatically terminated from the City’s health
plan on the last day of the month of his/her birthday. However, if you have a disabled child reaching the
age of 26, he/she may be eligible to continue dependent coverage. Contact the Benefits Service Center
at least three months before your child’s 26th birthday to apply for continued coverage for a disabled
dependent child.

Check the personalized Benefits Coverage Sheet to make sure the information is correct for you and your
dependents. Call the Benefits Service Center to update any of this information:
    • Name and birthdate.
    •	Social Security number if marked as “N”. If any Social Security number is marked “N”, you must bring
       the original Social Security Card to the Chicago Benefits Office to update your dependent’s record.

Federal law requires Social Security numbers for everyone enrolled in the City’s health plans.

IF YOUR HOME ADDRESS CHANGES
Contact your Department’s Human Resources Representative to update your address on file with the City.

ENROLLMENT CHANGES DURING THE YEAR

Benefit enrollment changes are allowed throughout the year only if you have a life change event such as
marriage, divorce, birth or adoption of a child or loss of coverage through your spouse. Call the Benefits
Service Center within 30 days of the life change event. If you try to make these changes as an open
enrollment change, the coverage will not go into effect until January 1, 2019. You must provide documents
to prove the life change event within 60 days of the event. Call the Benefits Service Center for more
information.

Please note: Life change events are effective on the event date but open enrollment changes are effective
January 1, 2019. When you call to make a life change event during the open enrollment period, you need
to make sure that you explain that you are calling about a life change event and ask for the benefits to
be effective on the event date.

Plan A effective 1/1/2019. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the
rank of Sergeant and Seasonal Employees). The Plan Document and subsequent updates always supersede this summary.
4
INSTRUCTIONS ON HOW TO ACCESS
                               www.cityofchicagobenefits PORTAL

Step 1: Employee ID Number

In order to create an online account, you will need your eight digit employee ID number.

Where to find your employee ID number?

Look on the upper left of your paystub where it says PAYEE/EMPLOYEE NUMBER. That’s it.

This is not your Kronos number, the number you use for City computer access, or your payroll number.

Step 2: Add Zeroes

For online open enrollment, your employee ID number needs to be eight digits long. Simply add zeroes at the
front to make it eight numbers. Examples: 5432 becomes 00005432 and 1234567 becomes 01234567.

Please keep this number for future use.

Step 3: Create Online Account

If you plan to enroll online, go to: www.cityofchicagobenefits.org to create your open enrollment username and
password to make sure you can get into the system. If you already have an online account, you can test it to
ensure it works.

If you’ve forgotten your username, click “Forgot Your User Name” and enter your eight digit employee
ID number. Follow the prompts to get your new username. If you’ve forgotten your password, click
“Forgot Your Password” then enter your username and follow the prompts. If you’ve forgotten both, get
your username first. If you’ve never used the system, click “First Time Logging In” and follow the prompts.

Step 4: Enrollment

   • Select benefits to enroll

   • Choose coverage: Single, Employee + One, Family

   • Enroll or re-enroll in the healthcare and dependent Flexible Spending Account (FSA) for 2019

Once you have made your enrollment selections ensure you click “submit” on the final screen.

Step 5: Write it Down

Keep your username and password; you need them to use the online open enrollment system in the future.

Plan A effective 1/1/2019. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the
rank of Sergeant and Seasonal Employees). The Plan Document and subsequent updates always supersede this summary.
                                                                                                                                5
ADDING A DEPENDENT DURING OPEN ENROLLMENT?
STEP ONE – Enroll your dependents. Enroll your spouse, civil union partner, same sex domestic
partner, and children during the open enrollment period online or by phone.

STEP TWO – Provide original documents to prove they are your legal dependents.
Submit your dependents documents as soon as possible. Your dependents will not have medical,
vision or dental coverage, effective January 1, 2019 if you fail to submit the required documentation
by December 6, 2018.

If you are adding dependents, you must submit the required documents for coverage to begin.
Deadline: If you submit your documents by close of business Thursday, December 6, 2018 coverage
will be reflected on January 1, 2019. For example, if your dependents seek medical care on January
1, 2019, your healthcare service provider will be able to verify coverage online. Please submit your
documents to the Chicago Benefits Office by this deadline to properly reflect coverage by the January
1st effective date. We encourage you to submit your documents right away to avoid the last
minute rush.
Grace Period. If you fail to submit your documents by Thursday, December 6, 2018, you may submit
documents through Thursday, January 31, 2019. Your failure to timely submit documents may result in
delayed coverage.
If you fail to submit documentation by the end of the grace period on January 31, 2019, you will be
required to wait until the next open enrollment period to enroll your dependents.

              Bring certified documents and your dependent’s social security card to:

                                               Chicago Benefits Office
                                          333 South State Street/Room 400
                                              Chicago, IL 60604-3978

                        Office hours are Monday through Friday 8:30 a.m. – 4:30 p.m.

             Your original certified documents will be copied and returned to you.
             Documents required are:

                  Spouse – certified marriage certificate and spouse’s social security card
                  Child – certified birth certificate and child’s social security card
                  Civil Union – certified certificate and partner’s social security card

Plan A effective 1/1/2019. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the
rank of Sergeant and Seasonal Employees). The Plan Document and subsequent updates always supersede this summary.
6
It should be noted that:

  • If healthcare services were received by your dependents during the grace period, and your medical provider
    submitted claims that were not paid because the required documents deadline of December 6, 2018
    was missed, those claims will be reprocessed retroactive to January 1, 2019 if the required enrollment
    documents are received by the Chicago Benefits Office by close of business January 31, 2019.

  • Your medical provider may need to resubmit claims.

  • Alternatively, if you paid out of pocket for healthcare services during the grace period, you may need to
    submit paper claims.

To avoid inconvenience, and to ensure your dependent’s new coverage is reflected at the time of service,
submit your documents to the Chicago Benefits Office by Thursday, December 6, 2018.

IMPORTANT NOTICE: If an employee or dependent gives false information, or if the dependent is not a
legal dependent of the employee, the City will take action to collect any money paid to cover healthcare
expenses related to the fraud and/or report the fraud to the appropriate authority.

                             DO NOT WAIT UNTIL THE LAST MINUTE

Plan A effective 1/1/2019. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the
rank of Sergeant and Seasonal Employees). The Plan Document and subsequent updates always supersede this summary.
                                                                                                                                7
ENROLL OR RE-ENROLL IN A FLEXIBLE SPENDING ACCOUNT (FSA)
Flexible Spending Accounts (FSA) may save you money by reducing your income taxes. An FSA allows you to have money
deducted from your paycheck before your federal and Social Security taxes are calculated. Your FSA contributions
are automatically tracked in a special FSA account administered by ConnectYourCare. You can choose to have FSA
reimbursement checks mailed to you or deposited directly into your bank account. You will have the option for a debit
card for healthcare flexible spending account.

FSA contributions are spread over the year and taken out each paycheck. After you decide how much you want to put
aside in an FSA, call the Benefits Service Center to enroll (1-877-299-5111) or enroll at www.cityofchicagobenefits.org.

HEALTHCARE FSA
A healthcare FSA allows you to set aside pre-tax dollars for qualified health expenses that are not covered by medical,
dental or vision insurance. Qualified expenses include deductibles, co-pays for medical care and prescription medications,
vision services and dental care. The maximum FSA contribution in 2019 is $2,650.

Estimate how much you will likely spend in 2019. Consider what medical, vision and dental expenses you are fairly certain
you will have next year including deductibles, co-pays and co-insurance amounts, as well as any out-of-pocket expenses
for services not covered by the plan (eye laser surgery, dental implants etc). A complete list of healthcare expenses for
FSA reimbursement can be found at www.irs.gov/pub/irs-pdf/p502.pdf.

DEPENDENT CARE FSA
Use pre-tax dollars to pay for care for a dependent child, disabled spouse, elderly parent or other tax dependents.
Qualified expenses include a babysitter, day care, preschool tuition, before and after school care and day camps for
dependents under age 13. Care for other tax dependents who are mentally or physically incapable of caring for themselves
also qualifies for FSA reimbursement. The maximum contribution in a Dependent Care FSA in 2019 is $5,000.

USE IT OR LOSE IT
The IRS requires that any money left in your account at the end of the year will be forfeited. If you enroll in either FSA
for 2019, qualified expenses have to be incurred before March 15, 2020. You will have until March 31, 2020 to submit your
2019 expenses.

If your employment with the City ends before you have used all the money in your FSA, you have until the end of the
annual grace period to submit expenses for FSA reimbursement (for example, March 31, 2020 for expenses incurred
in 2019 If you plan to incur expenses after your employment with the City ends, you must elect to continue FSA
contributions under PHSA/COBRA.

                                      DON’T FORGET TO RE-ENROLL!
                             You must re-enroll in the FSA each year during Open Enrollment

                                    www.cityofchicagobenefits.org
                                                  1-877-299-5111
                FSA enrollment cannot be done by ConnectYourCare
New FSA provider: You will continue to submit 2018 claims to PayFlex through March 31, 2019. Claims for
2019 will be processed by ConnectYourCare. More information coming soon.

Plan A effective 1/1/2019. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the
rank of Sergeant and Seasonal Employees). The Plan Document and subsequent updates always supersede this summary.
8
SPECIAL REMINDERS
PPO-Mandatory Second Opinion Program for Surgeries
A Second Opinion is needed before obtaining some surgeries. You must call Telligen as soon as your doctor
recommends surgery in any of the following areas:

      •   Knee; shoulder; hip; neck; and back
      •   Gall bladder
      •   Uterine, Vagina, Cervix
      •   Weight loss (Gastric Bypass)

There is no charge for the second opinion, you will not be examined and no travel is required. However, you must
give permission for the second opinion provider, Best Doctors, to collect your medical records and test results.

Telligen will first review your proposed surgery for medical necessity and if required, Best Doctors will then
arrange for a specialist to review your doctor’s diagnosis and recommendations. You will receive a confidential,
written report of the second opinion to help you decide how to proceed with treatment. You make the final
decision on whether to have surgery; however, if you do not get the second opinion, you will pay for the full
cost of the surgical procedure. The second opinion requirement is waived if you are admitted to the hospital for
surgery from the emergency room.

Call Telligen at 1-800-373-3727 to begin the second opinion review and out-patient surgery pre-certification
process. If you fail to obtain the required pre-certification, or the second opinion, you will pay for the full cost of
the surgical procedure.

PPO Virtual Doctor’s Visits
PPO members can have a virtual “face-to-face” medical evaluation by a primary care physician using a phone,
tablet or computer with a front facing camera. Claims are submitted directly to Blue Cross Blue Shield and
you pay a $20 copay for the visit. If necessary, prescriptions are sent to a local pharmacy, Value Formulary and
prescription drug copays apply. You must have a valid credit card to be able to use this service. Call Blue Cross
Blue Shield at 1-800-772-6895 for more information.

                   VOLUNTARY CHARITABLE PAYROLL CONTRIBUTIONS PROGRAM

City employees have the opportunity to extend their generosity to thousands of individuals and families
through the Employee Voluntary Charitable Payroll Contributions Program. Choose up to ten agencies to
receive your contributions from a list of 29 approved Chicagoland area charitable organizations. If you already
participate in the program, you can make changes, discontinue deductions, add new charities or increase
your contributions at any time. For more information, speak to your payroll administrator or download the
Charitable Contribution Allocation form at: http://www.cityofchicago.org/city/en/depts/fin/provdrs/payroll.
html under supporting information, “Charitable Giving”.

                                                   ONLINE PAY SLIPS

Sign up for GreenSlips, the City online pay slips program to view direct deposit of your paycheck online. You
can also view and download your W2 tax return as soon as available.

Go to https://greenslips.cityofchicago.org/TransformContentCenter/ and use your employee number to set up
a secure account.

Plan A effective 1/1/2019. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the
rank of Sergeant and Seasonal Employees). The Plan Document and subsequent updates always supersede this summary.
                                                                                                                                9
HEALTH
                       HEALTH CARE
                              CARE CONTRIBUTION
                                    CONTRIBUTION RATES RATES FOR
                                                              FOR 2019
                                                                  2019
                                Union
                       HEALTH CARE    and Non-Union
                                    CONTRIBUTION    Employees
                                                       RATES FOR 2019
                                Union and Non-Union Employees
                             (Contributions Union
                                            taken asand Non-Union
                                                     payroll          Employees
                                                             deductions; 24 pay periods each year)
                             (Contributions taken as payroll deductions; 24 pay periods each year)
                             (Contributions taken as payroll deductions; 24 pay periods each year)
  DENTAL & VISION INSURANCE
  DENTAL & VISION INSURANCE
  DENTAL
  PLAN & VISION INSURANCE
                       SINGLE                                     EMPLOYEE+1                                      FAMILY
  PLAN                                SINGLE                      EMPLOYEE+1                                      FAMILY
  PLAN
   DENTAL HMO
                                      SINGLE
                                      $0.20
                                                                  EMPLOYEE+1
                                                                   $1.08                                          FAMILY
                                                                                                                   $2.78
    DENTAL HMO                         $0.20                        $1.08                                            $2.78
    DENTAL HMO                         $0.20                        $1.08                                            $2.78
    DENTAL PPO                         $0.51                        $1.02                                            $2.05
    DENTAL PPO                         $0.51                        $1.02                                            $2.05
    DENTAL PPO                         $0.51                        $1.02                                            $2.05
    VISION                             $0.15                        $0.30                                            $0.61
    VISION                             $0.15                        $0.30                                            $0.61
    VISION                             $0.15                        $0.30                                            $0.61
  MEDICAL PLAN (HMO & PPO)
  MEDICAL PLAN (HMO & PPO)
  MEDICAL
  ANNUAL  PLAN (HMO & PPO)SINGLE
            SALARY                                                      EMPLOYEE+1                                FAMILY
   ANNUAL SALARY                             SINGLE                     EMPLOYEE+1                                FAMILY
   ANNUAL
  Up to $30,000 SALARY                       SINGLE
                                              $15.71                    EMPLOYEE+1
                                                                          $23.88                                  FAMILY
                                                                                                                   $27.65
  Up to $30,000                                $15.71                           $23.88                              $27.65
  Up to $30,000
  $30,001 and < $89,999                        $15.71
                                               1.2921% of payroll               $23.88 of payroll
                                                                               1.9854%                              $27.65 of payroll
                                                                                                                   2.4765%
  $30,001 and < $89,999                        1.2921% of payroll              1.9854% of payroll                  2.4765% of payroll
                                               ÷ 24                            ÷ 24                                ÷ 24
  $30,001 and < $89,999                        ÷ 24
                                               1.2921% of payroll              ÷ 24
                                                                               1.9854% of payroll                  ÷ 24
                                                                                                                   2.4765% of payroll
  Union Employee                               ÷ 24                            ÷ 24                                ÷ 24
  Union Employee                               $48.45                          $74.45                              $92.87
  $90,000 and above                            $48.45                          $74.45                              $92.87
  $90,000 and above
  Union Employee
  $90,000 and above                            $48.45                          $74.45                              $92.87
  Non Union  Employee
  Non Union  Employee                          $48.45                          $74.45                              $92.87
  $90,000 to $119,999                          $48.45                          $74.45                              $92.87
  $90,000 to Employee
  Non Union  $119,999
  $90,000 to Employee
             $119,999                          $48.45                          $74.45                              $92.87
  Non Union                                    1.2921% of payroll              1.9854% of payroll                  2.4765% of payroll
  Non Unionand
             Employee                          1.2921% of payroll              1.9854% of payroll                  2.4765% of payroll
  $120,000     above                           ÷ 24                            ÷ 24                                ÷ 24
  $120,000
  Non Unionand above
             Employee                          ÷ 24
                                               1.2921% of payroll              ÷ 24
                                                                               1.9854% of payroll                  ÷ 24
                                                                                                                   2.4765% of payroll
  $120,000 and above                           ÷ 24                            ÷ 24                                ÷ 24
  MEDICAL PLAN (HMO & PPO)*
  MEDICAL PLAN (HMO & PPO)*
  MEDICAL
  ANNUAL  PLAN (HMO & PPO)*
            SALARY       SINGLE                                         EMPLOYEE+1                                FAMILY
   ANNUAL SALARY                             SINGLE                     EMPLOYEE+1                                FAMILY
   ANNUAL
  Up to $30,000 SALARY                       SINGLE
                                              $15.71
                                                                        EMPLOYEE+1
                                                                          $23.88
                                                                                                                  FAMILY
                                                                                                                   $27.65
  Up to $30,000                                $15.71                           $23.88                              $27.65
  Up to $30,000                                $15.71                           $23.88                              $27.65
  $30,000 to $114,999                          2.2921% of payroll              2.9854% of payroll                  3.4765% of payroll
  $30,000 to $114,999                          2.2921% of payroll              2.9854% of payroll                  3.4765% of payroll
                                               ÷ 24                            ÷ 24                                ÷ 24
  $30,000 to $114,999                          ÷ 24
                                               2.2921% of payroll              ÷ 24
                                                                               2.9854% of payroll                  ÷ 24
                                                                                                                   3.4765% of payroll
                                               ÷ 24                            ÷ 24                                ÷ 24
  $115,000 and above                           $109.83                         $143.05                             $166.58
  $115,000 and above                           $109.83                         $143.05                             $166.58
  $115,000 and above                           $109.83                         $143.05                             $166.58

 *For recently ratified collective bargaining agreements.

 Plan A effective 1/1/2017. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the rank of
 Plan A effective
 Plan A effective1/1/2017.
                   1/1/2019.This
                             Thisisisa asummary
                                          summary of of benefits
                                                     benefits    offered
                                                              offered    to City
                                                                      to City    Employees
                                                                              Employees      (excluding
                                                                                         (excluding     Sworn
                                                                                                    Sworn       Police
                                                                                                           Police      Officers
                                                                                                                  Officers belowbelow  theof
                                                                                                                                 the rank
 Sergeant and Seasonal Employees). The Plan Document and subsequent updates always supersede this summary.
 rank of Sergeant
 Plan A effective
 Sergeant           and Seasonal
                  1/1/2017.
           and Seasonal           Employees).
                            This is a summary
                         Employees).               The  Plan
                                          The PlanofDocument Document
                                                     benefits offered    and  subsequent
                                                                      to City Employees
                                                               and subsequent              updates
                                                                                 updates (excluding always supersede
                                                                                                    Sworn Police
                                                                                         always supersede              this summary.
                                                                                                                  Officers below the rank of
                                                                                                           this summary.
10
 Sergeant and Seasonal Employees).     The Plan Document and subsequent updates always supersede this summary.                                 21
                                                                                                                                               21
                                                                                                                                               21
HEALTH CARE CONTRIBUTION RATES FOR 2019
                                                     CROSSING GUARDS
                           (Contributions taken as payroll deductions; 18 pay periods each year)

 DENTAL & VISION INSURANCE

 PLAN                              SINGLE                     EMPLOYEE+1                                     FAMILY

   DENTAL HMO                       $0.27                        $1.08                                         $2.78

   DENTAL PPO                       $0.68                        $1.36                                          $2.73

   VISION                           $0.20                       $0.40                                           $0.81

 MEDICAL PLAN (HMO & PPO)

  ANNUAL SALARY                           SINGLE                    EMPLOYEE+1                               FAMILY
 Up to $30,000                              $20.95                         $31.84                             $36.87

 $30,001 and < $89,999                      1.2921% of payroll            1.9854% of payroll                 2.4765% of payroll
                                            ÷18                           ÷18                                ÷18

 $90,000 and above                          $64.61                        $99.27                             $123.83

Plan A effective 1/1/2017. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the rank of
Plan A effective 1/1/2019. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the
 Sergeant and Seasonal Employees). The Plan Document and subsequent updates always supersede this summary.
rank of Sergeant and Seasonal Employees). The Plan Document and subsequent updates always supersede this summary.
22                                                                                                                                      11
PPO MONEY SAVINGS

 Save by using doctors and hospitals in the PPO Tier 1 network: The PPO gives you freedom to choose
 from three different network tiers. You can select doctors and hospitals (providers) from Tier 1 for some of your
 care, and use Tier 2 or Tier 3 providers for other services. You pay the lowest deductible and coinsurance when
 you use providers in Tier 1. To find a Tier 1 provider, call 1-800-772-6895 or go to www.bcbsil.com/cityofchicago.

 Two ways to save on prescription medications: 1) Choose generic medications and pay the lowest copay.
 2) Use mail order for long term “maintenance” medications. You will pay more if you don’t use mail order for long
 term medications after the 3rd fill. Just call 1-866-748-0028 and ask CVS Caremark to contact your doctor for a
 new prescription to be processed through mail order.

 Save on lab tests – use a free-standing lab: Get your lab tests paid in full by using a free-standing lab (such
 as a Quest lab) which is not affiliated with a hospital. Even if your doctor already has an arrangement with Quest,
 ask for a lab order for tests to be done at a Quest facility. Take this paperwork to the Quest lab and test results
 will be sent directly to your doctor. Call 1-866-697-8378 to find the location of a Quest lab near you, or go to
 www.Questdiagnostics.com.

 Save on scans – use a free-standing imaging center: Scans are covered in full if done at a free-standing imaging
 center. When your doctor orders an MRI, CT, or PET scan, call Telligen at 1-800-373-3727 to pre-certify the test
 and locate a free-standing imaging center near you.

 Pregnant? Earn a $100 incentive: Enroll in a free, confidential maternity management program designed
 to encourage a healthy baby by providing telephone support for moms-to-be. To qualify for the $100 incentive,
 call Telligen (1-800-373-3727) to enroll and complete at least eight doctors’ visits during the pregnancy.

 Plan A effective 1/1/2019. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the
 rank of Sergeant and Seasonal Employees). The Plan Document and subsequent updates always supersede this summary.
12
BLUE CHOICE OPTIONS MEDICAL PPO-PLAN A
                                             Blue Choice OPT                  Blue Cross PPO             Out-of-Network
                                                  Tier 1                           Tier 2                     Tier 3

Annual Deductible          Individual               $300                            $350                        $1,500
                           Family                   $900                            $1,050                      $3,000

Out-of-Pocket Limit        Individual              $1,000                           $1,500                      $3,500
                           Family                  $2,000                           $3,000                      $7,000
PREVENTIVE CARE                              YOU PAY                        YOU PAY                   YOU PAY
Routine checkups & routine lab work for
                                             $0 copay                       $0 copay                  No coverage out-of-network
adults & children; well-baby care; well-
                                             No deductible                  No deductible             for preventive care
women visits; mammograms; PSA;
colonoscopies, hearing screenings

OFFICE VISITS
Primary Care Physician, lab work,
                                           $20 copay does not             $25 copay does not          40% PPO allowed rate
x-rays, allergy shots,
                                           apply to deductible            apply to deductible         after out-of-network deduct-
Mental health and substance abuse
counseling                                                                                            ible plus balance billed by
                                                                                                      provider
Specialist Physician                        $30 copay does not            $35 copay does not
And Chiropractic Care (visit limits)        apply to deductible           apply to deductible
Annual deductible must be paid                   YOU PAY                          YOU PAY                    YOU PAY
before Plan covers these services:         After Tier 1 deductible          After Tier 2 deductible    After Tier 3 deductible

OUTPATIENT SERVICES*
Outpatient surgery MRI, PET                         10%                            25%                40% PPO allowed rate
& CT scan*                                                                                            plus balance
HOSPITAL SERVICES*
Hospital stay* including inpatient                  10%                            25%                40% PPO allowed rate
surgery                                                                                               plus balance
EMERGENCY ROOM CARE
Emergency Room                                                  $150 co-pay waived if admitted

Emergency Room Treatment                                                          10%

Ambulance emergency care                                             10% of PPO allowed rate

MENTAL HEALTH & SUBSTANCE ABUSE*
Inpatient hospitalization*                          10%                            25%                40% PPO allowed rate
Outpatient therapy*                                                                                   plus balance
ALTERNATIVES TO HOSPITAL CARE*
Skilled nursing facility*                           10%                            25%                40% PPO allowed rate
Home health care*, Hospice care*                                                                      plus balance
MATERNITY SERVICES
Maternity management program                                   No charge plus $100 cash incentive
Pre and post natal doctor visits            $20 copay (first visit)         $25 copay (first visit)   40% PPO allowed rate
Delivery and hospital stay*                           10%                          25%                plus balance

OUTPATIENT REHAB*
Physical therapy*                                     10%                          25%                40% PPO allowed rate
Occupational and speech therapy*                  $20 copay                     $20 copay             plus balance
OTHER SERVICES
DME*: Oral Surgery;                                   10%                          25%                40% PPO allowed rate
Ambulance transport between hospitals*                                                                plus balance

                         *Care must be pre-certified by calling Telligen at 1-800-373-3727. See the next page.
Plan AA effective
Plan    effective1/1/2017.
                  1/1/2019.This
                            Thisisisa asummary
                                         summary
                                               of of benefits
                                                  benefits    offered
                                                           offered    to City
                                                                   to City    Employees
                                                                           Employees     (excluding
                                                                                     (excluding     Sworn
                                                                                                Sworn      Police
                                                                                                      Police      Officers
                                                                                                             Officers belowbelow  theof
                                                                                                                            the rank
rank of Sergeant
Sergeant         and Seasonal
         and Seasonal         Employees).
                      Employees). The PlanThe Plan Document
                                           Document         and subsequent
                                                    and subsequent          updates
                                                                   updates always    always supersede
                                                                                  supersede           this summary.
                                                                                            this summary.
10                                                                                                                                        13
CERTAIN PPO SERVICES NEED TO BE PRE-CERTIFIED
 Telligen, the PPO medical advisor, needs to pre-certify the services listed below. There is a $1,000 penalty if Telligen is not contacted
 in a timely fashion in the event of a hospitalization. This $1,000 penalty does not go towards the deductible or get counted in the
 out-of-pocket maximum. Telligen’s phone number is 1-800-373-3727. This number is also on the back of the PPO ID card.

                               When To Call Telligen at 1-800-373-3727
 HOSPITAL ($1,000 penalty if Telligen is not called)
 Any inpatient stay in the hospital for medical, surgical,                  Call before elective admission or within two business
 maternity, mental health or substance abuse care.                          days of an emergency admission.
 Hospital outpatient treatment for mental health and substance              Call before the treatment begins.
 abuse

                        Plan pays nothing for the services listed below unless Telligen certifies
 AMBULANCE
 When ambulance is used for transfer between hospitals or to                Call before the transfer is arranged.
 hospital in a non-emergency situation
 SURGERY
 Organ transplant surgery
 Bariatric surgery               }      Must be done at a
                                      Blue Distinction Center               Call before surgery is scheduled.
 Gender reassignment surgery

 Inpatient and out-patient surgery for                                      Second Opinion review required.
 hips; back; neck; gall bladder; uterine, bariatric                         Call before surgery is scheduled to begin the man-
                                                                            datory second opinion process. Plan pays nothing if
 Outpatient surgery for knees                                               second opinion or pre-certification not obtained.

 MEDICAL EQUIPMENT
                                                                            Call before equipment is ordered if more than $500 for
 DME (durable medical equipment)                                            each item.
 OUTPATIENT THERAPY
 Mental health & substance abuse outpatient therapy/                        Call after a combined total of 7 sessions from one or
 counseling                                                                 more providers. Call each year if care is on-going.

 Occupational and speech therapy                                            Call after the 10th session each calendar year from one
                                                                            or more providers. Call each year if care is on-going.

 Physical therapy                                                           Call after the 7th visit. Call each year if care is ongoing.
 DIAGNOSTIC TESTS
                                                                            Call before test is done. Covered 100% if pre-certified
 MRI, PET & CT scans                                                        and done at a free standing facility. Deductibles and
                                                                            co-insurance amounts apply if pre-certified and done
                                                                            at a hospital facility or billed by a hospital.
 OTHER SERVICES
 Home health care                                                           Call before services start.

 Skilled nursing facility                                                   Call before being admitted.

 Sleep Study, Hospice, Infertility treatment, Non-surgical                  Call before services start.
 transplants, Other gender reassignment services

 Plan A
 Plan A effective
        effective 1/1/2017.
                  1/1/2019.This
                            Thisisisa asummary
                                        summary of of
                                                   benefits offered
                                                      benefits      to City
                                                               offered      Employees
                                                                       to City         (excluding
                                                                               Employees          Sworn
                                                                                           (excluding    Police
                                                                                                      Sworn     Officers
                                                                                                              Police     below
                                                                                                                     Officers  the rank
                                                                                                                              below theof
 rank of Sergeant
 Sergeant          and Seasonal
           and Seasonal          Employees).
                         Employees).     The PlanThe  Plan Document
                                                  Document             and subsequent
                                                             and subsequent              updates
                                                                               updates always     always supersede
                                                                                               supersede             this summary.
                                                                                                         this summary.
14                                                                                                                                          11
PPO PRESCRIPTION DRUG PROGRAM
                                    PPO PRESCRIPTION     DRUG
                                         Administered by CVS    PROGRAM
                                                             Caremark
                                                Administered by CVS Caremark

 PPO PRESCRIPTION MEDICATIONS                                                                   YOU PAY
 PPO PRESCRIPTION MEDICATIONS                                                                   YOU PAY
RETAIL - Short term medications                                            Generic $10 copay
If purchased
RETAIL        at aterm
         - Short   participating  retail pharmacy 34 day supply
                        medications                                        Preferred$10
                                                                           Generic      copay brand name $30 copay
                                                                                     formulary
or  100 units whichever  is less.
If purchased at a participating retail pharmacy 34 day supply              Non-preferred
                                                                           Preferred      brandbrand
                                                                                     formulary       $45 copay
                                                                                                namename $30 copay
or 100 units whichever is less.                                            Non-preferred brand name $45 copay

RETAIL - Maintenance or long term medications                              Generic $20 copay
The 4th -fillMaintenance
RETAIL        and any additional
                          or longrefills
                                    term medications                       Preferred$20
                                                                           Generic      copay brand name $60 copay
                                                                                     formulary
34 day
The 4thsupply
         fill andorany
                    100additional
                        units, whichever
                                  refills is less.                         Non-preferred
                                                                           Preferred      brandbrand
                                                                                     formulary       $90 copay
                                                                                                namename $60 copay
34 day supply or 100 units, whichever is less.                             Non-preferred brand name $90 copay

MAIL ORDER - Long term medications for chronic                             Generic $20 copay
conditions
MAIL ORDER - Long term medications for chronic                             Preferred$20
                                                                           Generic      copay brand name $60 copay
                                                                                     formulary
conditions                                                                 Preferred formulary brand name $60 copay
90 day supply
90 day supply
To get medications through the mail, send your doctor’s
prescriptions  to:
To get medications    through the mail, send your doctor’s
prescriptions to:
CVS Caremark
P.O.
CVS Box   94467
     Caremark
Palatine, IL 60094-4467
P.O. Box 94467
Palatine, IL 60094-4467
Call Caremark or visit its website for more information about
mail order.
Call Caremark   or visit its website for more information about
mail order.

Generic birth control                                                      $0 copay
Smoking  Cessation
Generic birth      medications
              control                                                      $0 copay
Smoking Cessation medications
                                                                           *$35 per household
Annual Rx Deductible
                                                                           *$35 per household
Annual Rx Deductible
VALUE FORMULARY
VALUE FORMULARY
Your plan has adopted the Value Formulary to encourage use of generics. Prescriptions not on the Value Formulary list will
be denied
Your        coverage
     plan has        at the pharmacy
               adopted                  and thetopharmacist
                            Value Formulary       encouragewill
                                                              usethen ask your physician
                                                                   of generics.           to substitute
                                                                                 Prescriptions          a Value
                                                                                               not on the  ValueFormulary
                                                                                                                  Formularydrug.
                                                                                                                              list will
be denied coverage at the pharmacy and the pharmacist will then ask your physician to substitute a Value Formulary drug.
If your physician does not agree to change the prescription, your physician must request an exception from CVS
Caremark
If          by submitting
   your physician  does notclinical
                              agree information
                                       to change for
                                                   the prior authorization.
                                                         prescription,          An approval
                                                                        your physician   mustorrequest
                                                                                                 a denial an will be faxed
                                                                                                              exception  fromto your
                                                                                                                                  CVS
Caremark by submitting clinical information for prior authorization. An approval or a denial will be faxed to prior
physician  and  mailed  to your  home    address.   Call CVS   Caremark    or visit the website  for  information   about  the    your
authorization
physician  andprocess
                mailed and the list
                        to your     of Value
                                 home        Formulary
                                         address.   Call drugs.
                                                         CVS Caremark or visit the website for information about the prior
authorization process and the list of Value Formulary drugs.
*$35 annual Rx deductible may vary based on collective bargaining agreement.
                                                  www.caremark.com
                                                  www.caremark.com
                                                   1-866-748-0028
                                                   1-866-748-0028

Plan A effective 1/1/2017. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the rank of
Plan A effective 1/1/2019. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the
Plan
rank Aofeffective
Sergeant
         Sergeant 1/1/2017.
           and Seasonal     This is a summary
                         Employees).
                    and Seasonal        The PlanofDocument
                                  Employees).      benefits offered
                                                 The                to City Employees
                                                             and subsequent
                                                     Plan Document            updates (excluding
                                                                       and subsequent            Sworn Police
                                                                                      always supersede
                                                                                        updates always        Officers below the rank of
                                                                                                       this summary.
                                                                                                       supersede   this summary.
Sergeant and Seasonal Employees). The Plan Document and subsequent updates always supersede this summary.
12                                                                                                                                         15
12
BLUE ADVANTAGE HMO* – A Blue Cross HMO
                                If care is pre-approved by your HMO primary care physician (PCP)
                                                              YOU PAY
 DOCTORS VISITS
 Primary Care Physician                                                   $25 copay

 Specialists                                                              $35 copay when approved by PCP

 Pre-natal visits                                                         $25 copay first visit

 HOSPITAL (all hospital services must be approved by PCP)

 Inpatient admission                                                      $20 copay

 Surgery (inpatient & outpatient)                                         $20 copay

 Maternity delivery                                                       $0 after $20 hospital copay
 Care in the hospital for mother & baby
 PREVENTIVE SERVICES

 Routine checkups for adults & children; well- baby care;                 $0 copay
 well-women visits; mammograms; DRE & PSA; colonoscopies,
 hearing tests
 EMERGENCY SERVICES (see next page for emergency coverage information)

 Emergency room treatment – life threatening                              $150 copay (waived if admitted)

 Ambulance – life threatening                                             You pay $0
 MENTAL HEALTH & SUBSTANCE ABUSE (must be pre-approved by PCP)
 Outpatient therapy                                                       $25 copay

 Inpatient care                                                           $20 copay each admission
 OUTPATIENT REHAB THERAPY (must be pre-approved by PCP)
 Physical, speech and occupational therapy                                $0 copay
                                                                          Limit of 60 visits combined each calendar year
 OTHER SERVICES (all other services must be pre-approved by PCP)

 Skilled nursing facility                                                 $0 Limited to 120 days a year

 Durable Medical Equipment (DME)                                          $0
 Hospice
 Home health care
 Ambulance transport between hospitals

 *HMO enrollment is available at the first open enrollment following 18 months of full-time City employment.

                                           www.bcbsil.com/cityofchicago
                                                 1-800-730-8504

 Plan A effective 1/1/2017. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the rank of
 Plan A effective 1/1/2019. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the
 Sergeant and Seasonal Employees). The Plan Document and subsequent updates always supersede this summary.
 rank of Sergeant and Seasonal Employees). The Plan Document and subsequent updates always supersede this summary.
16                                                                                                                                       13
HMO EMERGENCY CARE

The Blue Advantage HMO covers life threatening medical emergencies. It also covers care for acute medical problems
when pre-approved by your primary care physician (PCP).

What is a medical emergency?

A life threatening medical emergency is the sudden and unexpected onset of a potentially dangerous situation which, if
not treated immediately, could jeopardize your health. Such conditions are also severe and sudden in onset.

EMERGENCY ROOM TREATMENT                                                 You pay $150 copay – waived if admitted

Go to the nearest emergency room in the event of a life                  If possible, contact your PCP before seeking
threatening emergency                                                    emergency care. (Your PCP is available 24 hours a day,
                                                                         seven days a week.) In a life threatening emergency,
                                                                         call 911 and contact your PCP within 48 hours
                                                                         following emergency care.

AMBULANCE                                                                 You pay $0

For life threatening medical emergencies

TREATMENT IN PCP OFFICE                                                  You pay $25 copay if care is given in your PCP’s office.
                                                                         Call your PCP’s emergency number on the back of your
For acute medical problems which are not life threatening                Blue Advantage HMO ID card. A doctor or nurse will
                                                                         evaluate the problem and give instructions on where
                                                                         to go for medical care.

URGENT MEDICAL CARE AWAY FROM HOME                                        Call the toll-free emergency number on the back of
                                                                          your Blue Advantage HMO ID card.
For treatment for unexpected illness and injury when travel-
ling outside the Chicagoland area contact your PCP.                       If you or a covered dependent is away from home for
                                                                          more than 90 days, guest membership is provided at
                                                                          affiliate HMOs. Copays maybe different.

*HMO enrollment is available at the first open enrollment following 18 months of full-time City employment.

                                            www.bcbsil/cityofchicago
                                               1-800-730-8504

Plan A effective 1/1/2017. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the rank of
Plan A effective 1/1/2019. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the
Sergeant and Seasonal Employees). The Plan Document and subsequent updates always supersede this summary.
rank of Sergeant and Seasonal Employees). The Plan Document and subsequent updates always supersede this summary.
14                                                                                                                                      17
HMO PRESCRIPTION DRUG PROGRAM
                                    HMO PRESCRIPTION DRUG PROGRAM
                                               Administered by CVS Caremark
                                               Administered by CVS Caremark

     HMO PRESCRIPTION MEDICATIONS                                                                 YOU PAY
     HMO PRESCRIPTION MEDICATIONS                                                                 YOU PAY
  RETAIL - Short term medications                                           Generic $10 copay
  RETAIL - Short term medications                                           Preferred brand
                                                                            Generic $10     name $30 copay*
                                                                                         copay
  If purchased at a participating retail pharmacy                           Non-preferred
                                                                            Preferred brand namename
                                                                                           brand     $45 copay*
                                                                                                 $30 copay*
  34  day supplyatora 100
  If purchased            units whichever
                      participating         is less
                                    retail pharmacy                         Non-preferred brand name $45 copay*
  34 day supply or 100 units whichever is less

  RETAIL - Maintenance or long term medications                             Generic $20 copay
  RETAIL - Maintenance or long term medications                             Preferred$20
                                                                            Generic      copay
                                                                                      brand name $60 copay*
  The 4th fill and any additional refills                                   Non-preferred            $90 copay*
                                                                            Preferred brand namename
                                                                                           brand $60 copay*
  34
  Theday
       4thsupply
           fill andorany
                      100additional
                           units, whichever
                                     refills is less.                       Non-preferred brand name $90 copay*
  34 day supply or 100 units, whichever is less.
  MAIL ORDER                                                                Generic $20 copay
  MAIL ORDER                                                                Preferred brand
                                                                            Generic $20     name $60 copay*
                                                                                         copay
  Long term and maintenance medications for chronic                         Preferred brand name $60 copay*
  conditions
  Long  term and maintenance medications for chronic
  conditions
   90 day supply
   90 day supply
  To order medications through the mail, send your doctor’s
  prescription
  To             to:
     order medications      through the mail, send your doctor’s
  prescription to:
  CVS Caremark
  P.O. Box 94467
  CVS Caremark
  Palatine,
  P.O. Box IL   60094-4467
             94467
  Palatine, IL 60094-4467
  Call Caremark or visit their website for more information
  about  mail order.
  Call Caremark    or visit their website for more information
  about mail order.
  Oral Contraceptives (generic or brand)*                                   Generic $0 copay
  Oral Contraceptives (generic or brand)*                                   Preferred$0
                                                                            Generic     copay
                                                                                      brand name $30 copay*
                                                                            Non-preferred
                                                                            Preferred brandbrand
                                                                                            namename   $45 copay*
                                                                                                 $30 copay*
                                                                            Non-preferred brand name $45 copay*
  Smoking cessation medications                                             Certain generic medications $0 copay
  Smoking cessation medications                                             Certain generic medications $0 copay
  Annual Rx Deductible                                                **$35 per household
  Annual Rx Deductible                                                **$35 per household
  *If the member chooses brand when generic is available, member pays the cost difference between the brand and the
  generic  drug PLUS
  *If the member     the generic
                  chooses         co-pay.
                           brand when   generic is available, member pays the cost difference between the brand and the
 **$35
  genericannual
           drugRx deductible
                PLUS         may vary
                     the generic      based on collective bargaining agreement.
                                  co-pay.
                                                www.caremark.com
                                                www.caremark.com
                                                 1-866-748-0028
                                                 1-866-748-0028

 Plan A effective 1/1/2017. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the rank of
 Plan A effective 1/1/2019. This is a summary of benefits offered to City Employees (excluding Sworn Police Officers below the
 Plan
 rank Aofeffective
 Sergeant
          Sergeant 1/1/2017.
            and Seasonal     This is a summary
                          Employees).
                     and Seasonal        The PlanofDocument
                                   Employees).      benefits offered
                                                  The                to City Employees
                                                              and subsequent
                                                      Plan Document            updates (excluding
                                                                        and subsequent            Sworn Police
                                                                                       always supersede
                                                                                         updates always        Officers below the rank of
                                                                                                        this summary.
                                                                                                        supersede   this summary.
 Sergeant and Seasonal Employees).
18                                    The Plan Document and subsequent updates always supersede this summary.
                                                                                                                                            15
                                                                                                                                            15
DENTAL PROGRAM
                                                   DENTAL PROGRAM
                               Administered by Blue Cross Blue Shield of Illinois (BCBS)
                                  Administered by Blue Cross Blue Shield of Illinois
Enrollment in the dental plan is available after one calendar year of full-time employment. Separate contributions for
 Enrollment in the dental plan is available after one calendar year of full-time employment. Separate contributions for
dental coverage will be taken as payroll deductions. No action is needed if you want to continue your same dental
 dental coverage
coverage  in 2019.will be taken as payroll deductions.

IfIfyou
     youwant
         wantto
              toadd
                 addorordrop
                         dropdental
                              dentalcoverage
                                     coverageor
                                              orchange
                                                 change dental
                                                        dental plans
                                                                plans for
                                                                       for 2019,
                                                                           2019, visit
                                                                                 visit www.cityofchicagobenefits.org
                                                                                       www.cityofchicagobenefits.org or
                                                                                                                     or call
                                                                                                                        call
  the Benefits Service Center 1-877-299-5111 during open enrollment.
the Benefits Service Center 1-877-299-5111 during open enrollment.

BLUE CARE DENTAL PPO & HMO BENEFITS

                                            PPO In-Network           PPO Out-of-Network                HMO In-Network*

                                               YOU PAY                     YOU PAY                           YOU PAY

 Preventive                                   $10 copay              20% of PPO allowable         $10 copay for each
 (Two visits each year)                                              amount plus balance of       preventative visit
 Oral exams                                No deductible for         billed charges
                                           preventive services                                    No deductible in the HMO
 Cleanings
                                                                     No deductible for pre-
 X-Rays                                                              ventative servicesventive

                                                YOU PAY                     YOU PAY                          YOU PAY
 Annual deductible
 (amount each member pays first before
 plan pays benefits)                             $100                        $200                          No deductible

 Annual limit                               PLAN PAYS UP TO            PLAN PAYS UP TO
 (maximum amount a member receives
 in dental coverage each year after              $1,500                      $1,500                        No annual limit
 deductible has been paid)

                                               YOU PAY                     YOU PAY                           YOU PAY

 Restorative                                      20%                50% of PPO allowed            Copays of various amounts
 Endodontics                                      20%                amount plus balance of        (for information about co-pay
                                                                     billed charges                amounts visit www.bcbsil.
 Periodontics Surgery                             20%
                                                                                                   com/cityofchicago or call
 Oral Surgery                                     40%                                              1-855- 557-5487)
 Crowns                                           40%                                              Plan pays 100% after co-pay

 Orthodontics                                  Not covered                   Not covered           Covered for children of sworn
                                                                                                   police and uniformed firefighters
                                                                                                   up to age 25 with $1,800 copay.
                                                                                                   Coverage limited to age 19 for all
                                                                                                   others with $1,800 copay. Not
                                                                                                   covered for employee or spouse

*There is no coverage out-of-network in the Dental HMO. You must use dentists who participate in the Dental HMO.
For up-to-date information about HMO dentists visit the dental program website or call for more information.

                                         www.bcbsil.com/cityofchicago
                                              1-855-557-5487

Plan AA effective
Plan    effective1/1/2017.
                  1/1/2019.This
                            Thisisisa asummary
                                         summary
                                               of of benefits
                                                  benefits    offered
                                                           offered    to City
                                                                   to City    Employees
                                                                           Employees     (excluding
                                                                                     (excluding     Sworn
                                                                                                Sworn      Police
                                                                                                      Police      Officers
                                                                                                             Officers belowbelow  theof
                                                                                                                            the rank
rank of Sergeant
Sergeant         and Seasonal
         and Seasonal         Employees).
                      Employees). The PlanThe Plan Document
                                           Document         and subsequent
                                                    and subsequent          updates
                                                                   updates always    always supersede
                                                                                  supersede           this summary.
                                                                                            this summary.
                                                                                                                                          19
16
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